YOUTH CHARACTER FOOTBALL LEAGUE

YOUTH CHARACTER FOOTBALL LEAGUE

AN OUTREACH PROGRAM OF THE UNION Community Development Corporation
Participant Contract and Parental Consent Form Special Note: This form is applicable only for the current season. In addition to this form, the following items must be submitted, for your child to participate: Physical Form Completed by a Physician, Copy of Birth Certificate, Registration Fee.
Sport:*

FootballCheerleading
Did you participate last year?*

YesNo
Your Team Last Year or if you were a Cheerleader
Legal Name of Participant (must match birth certificate) LastFirst
Name*

First & Middle NameLast Name
MaleFemale
Birth date*

MonthDayYear
Date
Age*
Age as of August 31st*
Weight*
Height*
School*
Current Grade*
Your Child's Conduct?*
What subjects do you need the most help with?
Name of Parent/Guardian*

First NameLast Name
Relationship to Athlete*
Address*

Street Address

Street Address Line 2

CityState

Postal / Zip Code
Telephone: Home
Mobile
Work
Email Address*

Confirmation EmailRetype email to confirm
Emergency Contact Information (If parent/guardian cannot be reached)
Name*
Cell*
Relationship to Participant*
Please read Risk of Injury Release and Waiver and sign:

Acknowledgement of Risk of Injury Release and Waiver - I acknowledge and understand that there may be at risk of injury involved in the activities, which my child will engage in during the program. In consideration of the Union Community Development Corporation allowing my child to participate in the program and various field trips which may be taken on occasions, I hereby agree to release, waive, discharge, covenant not use, hold harmless and indemnify, on behalf of respective officials, agents, employees, directors, members, officers and other staff members from liability to us and our child, as well as our personal representatives, assigns, heirs and next of kin, for any and all claims, suits or causes of action from or out of any injury, known or unknown, to property or body, that my child may suffer from participation in the Union Baptist Character Football League activities, field trips or the above described Program; and do hereby expressly assume the risk of injury associated with participation in said Program.

Certification of Ability to Participate and Medical Authorization I, the undersigned, hereby certify that to the best of my knowledge my child is able to safely participate in the Program activities for which he/she has been registered. I, the undersigned, understand that in case of illness or injury of my child the Union Community Development Corporation Staff will try to notify me, or the emergency contact listed on the Program application form. In the event of a medical emergency concerning my child at a time when neither I nor the emergency contact person can be notified. I hereby authorize the Union Community Development Corporation Staff or my child's caregiver, as applicable, to obtain necessary medical care and/or treatment, including but not limited to first aid, X-ray, examinations, and aesthetic, medical or surgical diagnosis or treatment or hospital care and I hereby accept the sole financial responsibility for such medical care, first aid or treatment.
Hospital Preference: Accident Insurance Participants are responsible for their own accident insurance when participating in Union Community Development programs.
Blood Borne Pathogen Exposure: I understand that, while my child is in the care of Union Baptist Church, if a child is exposed to a body fluid or broken skin or mucous membrane, from another child, a Union Baptist Church Staff member will contact the parents of both children. They will explain what has occurred. and then approve the name of the attending physician of the source child to the parents of the exposed child. If a staff member has a blood or body fluid exposure from a child, the Union Community Development Corporation will provide the name and telephone number of the child's attending physician to the staff member. I have read and agree with the statement and specifically authorize Union Baptist Church to release the name and telephone number of my child's physician, and a description of the event to the parent or guardian of any child who is exposed to blood or body fluid or any staff member who experiences such exposure from my child. Initials above:
Please type your Initials*
Photographs: Photographs will occasionally be taken of the children during the Program. I, the undersigned, consent to the use of pictures of my child for displays, brochures and promotional materials with no compensation to my child or me. Initials below:
Please type your Initials*
Payment: Full Payment must be received before receiving equipment. All Fees are non-refundable and non-transferable. Initials below:
Please type your Initials*
I, the undersigned, have read this release and understand all of its terms. I execute it voluntarily and with full knowledge of its meaning and significance.
Signature*

Clear
Date*

MonthDayYear
Date
Youth Character Football League Participant & Parent/Legal Custodian Concussion Information Sheet

What is a concussion? A concussion is an injury to the brain caused by direct or indirect blow to the head. It results in your brain not working as it should. It may not cause you to black out. It can happen to you from a fall, a hit to the head, or a hit to the body that causes your head and your brain to move quickly back and forth.

How do you know if I have a concussion? There are many signs and symptoms that you may have, following a concussion. A concussion can affect your thinking, the way your body feels, your mood, or your sleep. Here is what to look for:
What should I do if I think I have a concussion? If you are having any of the signs or symptoms listed above, you should tell your parents, coach, athletic trainer or school nurse so they can get you the help you need. If a parent notices these symptoms, they should inform the school nurse or athletic trainer.

When should I be particularly concerned? If you have a headache that gets worse over time, you are unable to control your body, you throw up repeatedly or feel more and more sick to your stomach, or your words are coming out funny/slurred, you should let an adult like your parent, coach, or teacher know right away, so they can get you the help you need before things get any worse. What are some of the problems that may affect me after a concussion? You may have trouble in some of your classes at school or even with activities at home. If you continue to play or return to play too early with a concussion, you may have long term trouble remembering things or paying attention, headaches may last a long time, or personality changes can occur. Once you have a concussion, you're more likely to have another concussion.

How do I know when it's ok to return to physical activity and my sport after a concussion? After telling your coach, your parents, and any medical personnel around that you think you have a concussion, you will probably be seen by a doctor trained in helping people with concussions. Your school and your parents can help you decide who is best to treat you and help to make the decision on when you should return to activity/play or practice. Your school will have a policy in place for how to treat concussions. You should not return to play or practice on the same day as your suspected concussion.

You should not have any symptoms at rest or during/after activity when you return to play, as this is a sign your brain has not recovered from the injury.

This information is provided to you by North Carolina Medical Society, North Carolina Athletic Trainers' Association, Brain Injury Association of North Caroline, North Caroline Neuropsychological Society, and North Carolina High School Athletic Association.
Youth Character Football League Participant & Parent/Legal Custodian Concussion Statement Form

Instructions: The Participant and his/her parent or legal custodian must check each statement acknowledging that they have read and understand the corresponding statement. The participant should initial in the left column and the parent or legal custodian should initial in the right column. Some statements are applicable only to the student-athlete and should only be initialed by the participant. This form must be completed for each student-athlete, even if there are multiple students-athletes in the household. Participant Name (please print
Participant Name*
Parent/Legal Custodian Name(s)*
Parental and Participant Acknowledgement *

A concussion is a brain injury which should be reported to my parent(s)/or legal Custodian(s), my or my child’s coach(s), or a medical professional if one is available.A concussion cannot be “seen.” Some signs and symptoms might be present immediately, however, other symptoms can appear hours or days after an injury.I will tell my parents my coach and /or a medical professional about my injuries and illnesses.If I think a teammate has a concussion, I should tell my coach (s), parent(s)/legal Custodian(s) or medical professional about the concussion.I or my child, will need written permission from a medical professional trained in concussion management to return to play or practice after a concussion.Based on the latest data, most concussions take days or weeks to get better. A concussion may not go away, right away. I realize that resolution from a concussion is a process that may require more than one medical visit.I realize that ER/Urgent Care physicians will not provide clearance to return to play or practice, if seen immediately or shortly after the injury.After a concussion, the brain needs time to heal. I understand that I or my child is much more likely to have another concussion or a more serious brain injury if returned to play or practice occurs before concussion symptoms go away.Sometimes, repeat concussions can cause serious and long-lasting problems.I have read the concussion symptoms listed on the Student/Athlete/Parent Legal Custodian Concussion Information Sheet.I have asked an adult and/or medial professional to explain any information contained in the Student-Athlete & Parent Concussion Statement Form or Information Sheet that I do not understand.
By signing below, we agree that we have read and understand the information contained in the Participant & Parent/Legal Custodian Concussion Statement Form and have initialed appropriately beside each statement.
Signature of Participant*

Clear
Date*

MonthDayYear
Date
Signature of Parent/Legal Custodian*

Clear
Date*

MonthDayYear
Date
Please note that if the needed information is not submitted in a timely manner, it could risk your child's chances to participate with the league this season.

Union Caommunity Development Corporation I 1200 N. Trade Street, Winston-Salem, NC 27101 I Phone: 336-779-4868
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